983
Total cases
45%
Preventable or possibly preventable
53%
With coroner recommendations
29%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
61y · Female·Unascertained (natural causes)
Ms Harris, aged 61, with intellectual disability, autism spectrum disorder, and multiple medical conditions (including aortic regurgitation, hypothyroidism, dyspnoea, hyperlipidaemia, and obesity), was living in supporte…
77y · Male·Congestive cardiac failure with an antecedent cause of ischaemic cardiomyopathy …
Alan Frederick Cornish, aged 77, died in lawful custody at Long Bay Hospital on 1 September 2025 from congestive cardiac failure with ischaemic cardiomyopathy, complicated by chronic kidney disease, COPD, and type 2 diab…
38y · Female·Pulmonary thromboembolism secondary to deep venous thrombosis due to promethazin…
Elizabeth Jean Hanlon, aged 38, died from pulmonary thromboembolism secondary to deep venous thrombosis following a promethazine overdose. She had complex mental health diagnoses including borderline personality disorder…
40y · Male·Unascertained
Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…
73y · Male·Thromboembolism on a background of a spindle cell tumour
Michael Anthony Guider, aged 73, was an inmate in NSW correctional custody when he developed progressive shortness of breath and lower limb swelling. He presented to Prince of Wales Hospital on 6 September 2024 and was f…
71y · Male·metastatic papillary renal cell carcinoma
Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…